Breathing health into a stone?

Are my emotions mine? That is, do they live inside me, or are they things that are shared -exist between me and others, in other words? Are they more the combination of genetic predisposition and situational features which are dependent on societal norms that we were taught from our early years at home and in the community?

It seems to me that it is an important point: where should we direct our efforts if we feel  emotions are getting out of hand? Is simply treating me sufficient, or am I the fabled canary in the coal mine? I’ve been retired from specialist medical practice for some years now, and I can feel my loyalties shifting. It’s not that I have joined the dark side, or anything -more that I can see both sides better from the border.

If we are to confront medical skepticism, it is a good idea to examine it from a historical perspective. I found a helpful essay by Bernice L. Hausman, professor and chair of the Department of Humanities at the Penn State College of Medicine in Hershey, Pennsylvania: https://aeon.co/essays/what-explains-the-enduring-grip-of-medical-skepticism

Early in her explanation, she writes that ‘while medical therapeutics have advanced considerably, many current treatments are also aggressive… Consider the expansion of disease categories to include personality quirks and body types, side-effects that demand further medications, drug interactions that are deadly, and medical supervision of things left well enough alone. If 18th-century medicine lacked a scientific basis, our problem might be too many therapies for our own good. The expansion of treatment has led to a critical response – ‘medicalisation’, which describes a skeptical approach to mainstream medicine’s social role in defining health.’

Indeed, what is ‘health’? Is it merely a state of being free of injury or illness, or is there something else involved as well? Something that medicine often fails to address: who has the social authority to decide what constitutes health -not so much for society as a whole, but for the individual? And how it should best be treated, for that matter?

Take an old example: TB. The proximate cause, of course, is the tuberculum bacillus, Mycobacterium tuberculosis, but in some sense the bacterium is merely opportunistic. The ultimate, or distal cause may well be something like impaired immunity from malnutrition or poverty. So, which cause should be addressed -the proximate one, of course, but should we leave it at that? Is it enough to rub our hands and say ‘done’? For that matter, to whom should we look for a remedy?

But, the problem is still with us -for example, the current pandemic of Covid 19 with its massive social and economic upheavals. From time to time, there has been promulgated the exculpatory mantra that the virus knows no boundaries; the virus does not discriminate, unlike our political borders. But of course it does. The communities of colour -African American and Latino, in America at least- seem to be disproportionately affected. Why? Well, there are a few obvious factors at play. ‘African-Americans have higher rates of underlying conditions, including diabetes, heart disease, and lung disease, that are linked to more severe cases of COVID-19′. And, ‘They also often have less access to quality health care, and are disproportionately represented in essential frontline jobs that can’t be done from home, increasing their exposure to the virus,’ according to a report (May30/2020) from NPR.

And, from the same report, ‘Latinos are [also] over-represented in essential jobs that increase their exposure to the virus… Regardless of their occupation, high rates of poverty and low wages mean that many Latinos feel compelled to leave home to seek work. Dense, multi-generational housing conditions make it easier for the virus to spread.’ Of course, by now that is old hat… isn’t it?

I suspect I saw it differently when I was in practice, but perspective is often beguiling -the old aphorism about the hammer and the nail, perhaps? ‘In Medical Nemesis (1975), Illich [the intellectual iconoclast, Ivan Illich, a Croatian-Austrian Catholic priest] made a starkly prescient argument against medicine as a dangerous example of what some call ‘the managed life’, where every aspect of normal living requires input from an institutionalised medical system. It was Illich who introduced the term ‘iatrogenesis’, from the Greek, meaning doctor-caused illness. There were three levels of physician-caused illness, as far as he was concerned: clinical, social and cultural. Clinical iatrogenesis comprises treatment side-effects that sicken people. Social iatrogenesis describes patients as individual consumers of treatment who are self-interested agents rather than actively political individuals who could work for broader social transformations to improve the health of all.

But, cultural iatrogenesis is the one that interests me the most, I must admit: that ‘people’s innate capacities to confront and experience suffering, illness, disappointment, pain, vulnerability and death are [being] displaced by medicine.’

Illich thinks that ‘medicine takes a technical approach to ordinary life events, hollowing out the rich interpersonal relations of caring that defined being human for millennia.’ But to be fair, Illich still felt that ‘Sanitation, vector control, inoculation, and general access to dental and primary medical care were hallmarks of a truly modern culture that fostered self-care and autonomy.’ He was more concerned with the impersonal bureaucracy that surrounded medicine. An interesting criticism, and one that I also share -albeit one that seems to stem from the medical system as he saw it from south of our Canadian border.

And yet I think the thrust of Hausman’s essay was more a reaction to the disillusionment that followed the initial promise of modern medicine. Things like delegating the definition of health to professionals who have a vested interest in defining it in a way that seems to mandate the continued need for them. I think this view is unfair, but, given Illich’s iatrogenesis concerns, I can see how that attitude might seem plausible.

Have we doctors been -are we still- sometimes too aggressive in our treatments, too arrogant in our knowledge, too certain of our advice, and too resistant to alternative approaches? I’m not suggesting that we cave to pseudoscience, or acquiesce to theories just because they are currently fashionable; Science is never perfect, and is open to change. But still, primum non nocere is a good aphorism to guide us: First of all, do no harm. I seem to remember promising something like that in my medical oath…

What is the Merit of Originality?

‘I am not young enough to know everything,’ as Oscar Wilde once said, and maybe the rest of us aren’t either. It is often an unquestioned assumption that New trumps Old, that innovation usually leads to improvement, and that by standing on the shoulders of giants, the view is necessarily better. Clearer.

But there is wisdom in both the long as well as the panoramic views. Neither changing  your shoes nor altering your hat, really improves the safety of a voyage -nor does it address the original goal of a safe arrival of everybody on board. Appearing modern, seeming prepared, only helps if it helps –a leak is still a leak, especially if there are only lifeboats for a few…

Let me explain. I happened upon an article in the journal Nature that chronicled the introduction of a new, and highly accurate method of diagnosing TB through genetic analysis.  https://www.nature.com/news/improved-diagnostics-fail-to-halt-the-rise-of-tuberculosis-1.23000?WT ‘The World Health Organization (WHO), promptly endorsed the test, called GeneXpert, and promoted its roll-out around the globe to replace a microscope-based test that missed half of all cases.’ It sounded like a perfect technological fix for a disease that has so far avoided effective control. ‘Some 10.4 million people were infected with TB last year, according to a WHO report published on 30 October [2016?]. More than half of the cases occurred in China, India, Indonesia, Pakistan and the Philippines. The infection, which causes coughing, weight loss and chest pain, often goes undiagnosed for months or years, spurring transmission.’

Unfortunately, ‘[…] the high hopes have since crashed as rates of tuberculosis rates have not fallen dramatically, and nations are now looking to address the problems that cause so many TB cases to be missed and the difficulties in treating those who are diagnosed. […] The tale is a familiar one in global health care: a solution that seems extraordinarily promising in the lab or clinical trials falters when deployed in the struggling health-care systems of developing and middle-income countries. “What GeneXpert has taught us in TB is that inserting one new tool into a system that isn’t working overall is not going to by itself be a game changer. We need more investment in health systems,” says Erica Lessem, deputy executive director at the Treatment Action Group, an activist organization in New York City.’

But I mean, just think about it for a minute. ‘The machines cost $17,000 each and require constant electricity and air-conditioning — infrastructure that is not widely available in the TB clinics of countries with a high incidence of the disease, requiring the machines to be placed in central facilities.’ Sure, various groups agreed to subsidize the tests in 2012, but: ‘each cost $16.86 (the price fell to $9.98), compared with a few dollars for a microscope TB test.’ So which test would you choose if you were a government strapped for cash to provide for healthcare for a broad spectrum of other equally pressing needs?

‘Even countries that fully embraced GeneXpert are not seeing the returns they had hoped for. After a countrywide roll-out begun in 2011, the test is available for all suspected TB cases in South Africa. But a randomized clinical trial conducted in 2015 during the roll-out found that people diagnosed using GeneXpert were just as likely to die from TB as those diagnosed at labs still using the microscope test.’ That seems counterintuitive to say the least.

So what might be happening? ‘Churchyard [a physician specializing in TB at the Aurum Institute in Johannesburg, South Africa] suspects that doctors have been giving people with TB-like symptoms drugs, even if their microscope test was negative or missing, and that this helps to explain why his team found no benefit from implementing the GeneXpert test. Others have speculated that, by being involved in a clinical trial, patients in both arms of the trial received better care than they would otherwise have done, obfuscating any differences between the groups.’

‘Even with accurate tests, cases are still being missed. Results from the GeneXpert tests take just as long to deliver as microscope tests, and many people never return to the clinic to get their results and drugs; those who begin antibiotics often do not complete the regimen.’ Clearly, technology alone, without an adequate infrastructure to support it –without a properly funded and administered health care system- is not sufficient.

And it’s simply not enough to have even a well-funded health system that benefits just those who can afford it, leaving the rest of the population to fend for itself, and only seeking help when they can no longer cope –often when it is too late. Health care is a right, not a privilege –no matter what those in power would have us believe.

I’m certainly not arguing that improving technology is not part of the solution, but sometimes I wonder if it is merely putting new clothes on a beggar. Handing out flowers in a slum.

Let’s face it, real Health Care is more than a sign on a door, more than a few people in white coats. It is a kind of national empathy. A recognition that even the poorest among us, have something valuable to contribute; that even those who have strayed from society’s chosen path, are who any of us might be, but in different clothes.

The myth of Baucis and Philemon tugs at my memory: They were an old married couple living in a small village in Anatolia (part of Asian Turkey nowadays) who, unlike everyone else in the town, welcomed two peasants at their door who were seeking refuge for the night. The couple, of course, were unaware that they were actually welcoming two gods, Zeus and Hermes, disguised as humans. A common enough trope, perhaps, but an instructive one, I think -one that transcends virtually all cultures, and borders: the idea of helping others without any expectation of reward. It is not an exchange -a transaction- so much as an action. Agape, in fact.

Health care is like that. Or should be… It’s not about the glittering display in the shop window –there to impress the passersby- it’s about the people in the shop.